J.D. a 42-yr old female, admitted to medical unit at the hospital for exacerbation of multiple
sclerosis. Signs/symptoms include fatigue, generalized weakness, ataxic gait, occasional blurred
vision, urinary frequency
...
J.D. a 42-yr old female, admitted to medical unit at the hospital for exacerbation of multiple
sclerosis. Signs/symptoms include fatigue, generalized weakness, ataxic gait, occasional blurred
vision, urinary frequency and urgency, and constipation.
Medications include Rebif 22mcg SQ injection M, W, Sa 1800; Aubagio 7mg PO QD; Ditropan
15mg PO QD; Solu-Medrol 1gm IVPB Q4H given over 30min; Trazodone 50mg PO QHS PRN
sleep.
Lab values include: RBC 4.3 x 106
/µL; Hgb 11.5 g/dL; Hct 33%; WBC 4500/µL; Platelets
301,000/µL; ALT 103 U/L; AST 143 U/L.
VS: BP 145/103, P 96, RR 22, T 36.8˚C, O2Sat 96%.
1. What priority physical assessment will the nurse perform upon admission?
Objective data:
-General: Apathy, inattentiveness
-Integumentary: Pressure ulcers
-Neurologic: Scanning speech, nystagmus, ataxia, tremor, spasticity, hyperreflexia,
decreased hearing (Lewis et. all., 2017, p.1386).
2. What priority health history questions would the nurse ask?
Subjective data:
-Past health history: history or present viral infections or vaccinations, any recent
infections, living in cold or temperate climates, stress (physical or emotional), if
pregnant, any exposure to heat & cold.
-Medications: if adhering to medication regimen of corticosteroid, immunomodulators,
immunosuppressants, cholinergic, anticholinergics, antispasmodics.
-Health perception-health management: positive health history; malaise
Nutritional-metabolic: weight loss; difficulty in chewing, dysphagia.
Elimination: urinary frequency, urgency, dribbling or incontinence, retention
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